Buprenorphine can be safely continued during perioperative pain management in patients taking it for opioid use disorder, researchers report.  "Contrary to conventional thinking, continuation of buprenorphine at low to moderate doses doesn't make pain control more difficult and has benefits beyond pain management, such as avoiding withdrawal and relapse during the peri-operative period," Dr. Yi Zhang. 

Buprenorphine is a partial mu-opioid receptor agonist that is effective as maintenance therapy for opioid use disorder (OUD). Some have questioned whether acute pain can be effectively controlled in patients when buprenorphine is continued perioperatively, while others are concerned about the risk of OUD relapse if opioid maintenance therapy is discontinued perioperatively.

Analgesic efficacy 

Dr. Zhang and Dr. Aurora Naa-Afoley Quaye reviewed the available literature on buprenorphine and its analgesic efficacy combined with full mu-opioid agonists in an effort to resolve questions about the safety and effectiveness of continuing buprenorphine perioperatively.

According to their review, preclinical and clinical studies have shown that at analgesic doses, the combination of buprenorphine and mu-agonists elicits an additive and possibly synergistic analgesic response. Antagonistic effects have been seen only when buprenorphine was used at doses higher than analgesic doses.

They found no high-level evidence to support a consensus pain management strategy, according to the Pain Medicine online report. Four case reports supported periprocedural discontinuation of buprenorphine, while periprocedural continuation was supported by two case series, one secondary observational study, one prospective matched cohort study, and four retrospective cohort studies. There have been no relevant clinical trials.

"We do not know what the optimal dose of buprenorphine is to maintain patients on during the perioperative period," Dr. Zhang said. "Based on our summary of current knowledge, we recommended a dose of 16 mg daily before surgery and a dose of 8 mg daily on and after the day of surgery."

Clinical trials 

"Further research, ideally in the form of a randomized clinical trial, is needed to identify the optimal dosing strategy," he said. Dr. Zhang added that the ultimate decision should result from an informed discussion between the patient and the physician.

Dr. T. Kyle Harrison from Stanford University in California, who recently reviewed perioperative considerations for patients on opioid maintenance therapy. "The approach is evolving, and what has been published in the past is not based on clinical evidence but rather expert opinion. The authors have appropriately reviewed the current evidence and hopefully this can help to disabuse providers' belief that buprenorphine should be held in the perioperative setting."

"We try to approach each patient individually, but as a general principle I would never support discontinuing buprenorphine," he said. "The gray area is should they be tapered down or not. The dose needed to prevent withdrawal is lower than the dose needed to prevent cravings; thus, some patients can be weaned to a lower dose preoperatively, but I am not sure that is a good idea to wean at all. We have recently been continuing patients on higher doses throughout the perioperative period and still have been able to provide adequate pain relief."